Early identification and treatment, both medical and psychological, is key

Two linked patient journeys describe the experience of male puberty gone awry (doi:10.1136/bmj.e6938, doi:10.1136/bmj.e6971). Puberty is a period of substantial physical development that culminates in reproductive capacity, and it is marked by major psychological changes. The normal timing of puberty is influenced by several factors, including those that are familial, ethnic, and environmental. It is estimated that genetic factors account for 50-80% of the variance in the onset of puberty.1 Accumulating evidence suggests a secular trend towards decreasing age of onset of puberty, which could be related, in part, to obesity.12 Failure to initiate spontaneous puberty, which represents the extreme end of the pubertal spectrum, could trigger presentation to medical services for a number of adolescents. For the clinician faced with an adolescent male patient who is not developing signs of starting puberty, differentiating normal variation from pathology is not always straightforward. However, as the linked patient stories clearly show, failure to deal with clinical concerns in a timely fashion for such patients can have longlasting psychological and emotional effects.

Delayed puberty is defined as the absence of testicular enlargement in boys 2 to 2.5 …